Demographics Form Go backYour message has been sent Thank you for your interested in my services. Please complete the following form with the intended client’s information. If you are interested in couples therapy, please complete a form for both individuals. This information will be emailed directly to Jenn Teutscher. I look forward to working with you! Legal First and Last Name(required) Warning Todays Date Warning Date of Birth(required) Warning Address(required) Warning Email(required) Warning May I contact you via email?(required) Yes No Warning May I email you forms through Adobe Acrobat Sign?(required) Yes No Warning Phone Number(required) Warning May I contact you on this number?(required) Yes No Warning Insurance Provider/Plan Name Warning Insurance Patient ID Warning How did you hear about me? Warning If client is MINOR, person responsible/guardian (please identify NAME, RELATION, AND PHONE NUMBER). Warning Emergency Contact Information Emergency Contact Name(required) Warning Relationship to Emergency Contact(required) Warning Emergency Contact Phone Number(required) Warning Identity Information Ethnicity/National Origin Warning Current Religious Denomination/Affiliation Warning Religious/Spiritual Involvement None Some/Irregular Active Warning Gender Identity Female Male Transgender Non-binary Gender Neutral Pangender Genderqueer Warning Sexual Orientation Asexual (lack of sexual interest in either men or women) Bi-Sexual (sexual interest in both men and women) Gay/Lesbian (sexual interest in a member of the same sex) Heterosexual (sexual interest in a member of the opposite sex) Questioning (still exploring or unsure of sexual orientation) Warning Other related way you identify yourself and consider important Warning Warning. SendSubmitting form Δ
Jenn Teutscher, LMFT 